Managing pain in elderly patients at home

Nursing, Aug 2001 by Gallagher, Bridget

Controlling Pain

QUESTION: Among elderly people living in the community, 25% to 50% are living with pain, according to some estimates. If this is so, why are the elderly among the most undertreated for pain?

ANSWER: Research into this issue has uncovered several explanations. Because pain is a subjective experience, clinicians rely on patient reporting, yet many elderly patients are reluctant to report pain. Their reluctance may stem from the fear of additional testing or treatment, addiction issues, or concerns about adverse reactions to medications. Some patients are unwilling to acknowledge pain because they view it as a metaphor for serious disease or death. Further complicating matters, some clinicians mistakenly believe that sensitivity to pain decreases with aging. And finally, patients and clinicians alike may consider pain a "normal" part of daily life for older adults.

Because of the paucity of pain care protocols for elderly adults living in the community, our home health care agency took these steps to develop our own pain management program.

Taking a multidisciplinary approach. During a two-stage process, we selected a pain management action team made up of nurses, physical therapists, occupational therapists, social workers, and physicians. Team members then conducted an extensive literature review to educate themselves about the issue. Team members rotated to promote maximum staff input and prevent burnout.

Selecting or developing appropriate assessment tools. Next, the team designed a one-page pain assessment sheet appropriate for our elderly clients. It incorporated elements of several standard pain assessment tools, including a numeric and a FACESpain rating scale, a body map for documenting pain location, and sections for documenting the intensity, quality, onset, and effectiveness of patient-initiated pain management measures. Nurses also designed a user-friendly pain management letter to serve as a care plan and to provide community primary health care providers with a written record of the interventions planned.

Educating patients and staff. The pain action team devel

oped an education program for staff members consisting of guest speakers with expertise in various pain-related topics. The team also distributed articles on key pain management topics, including fallacies of pain in the elderly. Staffdevelopment sessions reinforced the need to address and manage pain routinely.

Fostering patient participation. To enlist the cooperation of patients and their families, the action team developed the Pain Monitoring Record, which allows a nurse to assess the effectiveness of pain management interventions during home health care visits. At the end of the month, the entire team, including the patient, evaluates the effectiveness of pain management measures and decides on the next step to follow. Options for follow-up include another month of the pain management program, a revisit to the primary care provider, or referral to a pain clinic or specialist.

Evaluating the pain program. Because levels of

compliance varied and intervention occurred in patients' homes, we needed a consistent evaluation plan. We use the Outcome and Assessment Information Set (OASIS) mandated by the Centers for Medicare and Medicaid Services (Health Care Financing Administration). Conducted at the first home health care visit and at specified intervals during care, OASIS tracks the patient's pain while evaluating the impact of the pain management program.

We intend to continue evaluating the effectiveness of the program, educating the staff, and revising the pain assessment tools to make them even easier to use.

This department is posted on-line along with an extended list of references on this topic. Visit the table of contents for this issue at http://springnet.com/ jrdescr/nurse98toc.htm (click on "departments" at the right of the screen).

SELECTED REFERENCES

American Geriatrics Society: "The Management of Chronic Pain in Older Persons: AGS Panel on Chronic Pain in Older Persons," Journal of the American Geriatric Society. 46(5):635-651, May 1998.

McCaffery, M., and Pasero, C.: Pain: Clinical Manual, 2nd edition. New York, N.Y., Mosby, Inc., 1999.

BY BRIDGET GALLAGHER, GNP, MSN

Director of Patient Services * The Jewish Home and Hospital Home Health Care Program * New York N. Y.

Contributing authors and pain management team members include Romel Bote, RN; Ellen Corbett, PT; Anneliese Haberl, MSW; Trudy Lee, RN; Michael Milton, MSW; Blanca Montalvo, RN; Cathy Smith, RN; and Amy Zarrow, RN.